As per my usual routine when the kids are doing their own thing after dinner, I put some YouTube videos on my tablet/netbook whilst tacking the Sunday night dishes this past week. Though I'm pretty fastidious when it comes to making sure there's no bug-attracting mess once I'm done in the kitchen, I've never been able to keep the process all that neat. I'm notorious for splashing water all over the place when I wash dishes, and Sunday night was no exception.
Unfortunately, I splashed more than a few drops on my netbook, and woke up this morning to discover about one out of five keys non-functional. I spent an hour or so taking the thing apart and cleaning out the insides. No luck. Another hour scouring the net for alternative solutions or a replacement keyboard. Strike two. Two hours (including travel time) to the computer store, experimenting, sizing, comparison shopping, installing...hey! I've got a netbook working again, for only one-third the cost of a new machine, albeit with a second fucking keyboard to schelp around. See, I couldn't find a smallish keyboard with a built-in mouse, and I can't clog up the lone USB port with a mouse because I need the port for the jump drive demanded by the Coroner's Record software, and by this point if you're still reading I have no doubt you give not the slightest shit.
Which brings me to what has been proffered for almost 20 years as the absolute, unquestioned, no-two-ways-about-it solution to so many problems in our health care system: the Electronic Medical (or Health) Record, or EMR.
Like anybody that remembers when computers moved beyond the world of glorified game consoles and into functional, even essential tools, I thought EMRs were the Holy Grail of medical practice. Imagine...you see a patient, look up their test results, see a complete list and flow chart of their medications, read their consult notes, and craft your own note that's free of the legally indefensible, illegible pseudo-hieroglyphs doctors are notorious for. EMRs would allow the health care team to do serious quality assurance work, streamlining processes and keeping lines of communication open between various members of the health care team.
So how's it working out for us? Like most Bright Ideas in Health Care, EMRs have created as many, if not many more problems as they've supposedly fixed. First, the cost. Obviously Ontario deserves special mention here, having pissed away obscene amounts of money on E-health not even Sherlock Holmes could track down. But even if we forget about the waste - not every jurisdiction is Ontario, after all - have EMRs added any value to the work of health care? Do legible notes and prescriptions, and fewer duplicated tests make up for the costs of training staff on EMR systems (that are often very different from one another)? Of maintaining the quick-to-obsolesce hardware? Of adding capacity? Of internet connections with adequate bandwidth? Of the permanent need for IT personnel? Especially these days, when health care budgets are consumed faster than they can be prepared?
Then we have to look at what EMRs do to the actual practice of patient care. Peer-reviewed research indicates there's a productivity loss (number of patients seen per day) with EMRs that's permanent. Why? Because with paper records, charting on a simple visit (say, a minor infection or blood pressure check) takes seconds. I can record "OM ® ear, Rx Amoxil 500mg TID x 10/7" in a flash. So long as it's legible, any doctor or nurse practitioner in the country would read that as "otitis media (ear infection) of the right ear, treated with amoxicillin 500mg three times a day for ten days". Seconds to chart. On an EMR? At least two to three minutes, and that's before making sure I've plugged in the correct service codes. And hoping the mouse doesn't go haywire. And the keyboard doesn't throw a hissy fit and start misspelling everything. And the internet doesn't freeze up.
Then you have the absurd situation of a clinic being unable to function without an operational EMR. A simple blackout in broad daylight, a problem with the ISP, Russian hackers...all of a sudden my training and experience are of next-to-no use to my patient, because I can't go over results nor print off a prescription without a functioning EMR.
More than any question of productivity or financial costs, though, is the toxic effect EMRs have on the very nature of patient care. How often do you hear people bemoan the omnipresence of smartphones and e-communication as corrosive to basic human contact? Well, here's a newsflash...medicine is no different. That two minutes eaten up by EMR charting for a simple problem? That used to be taken up with small talk, maybe the sharing of good news. Or to grab a breather before seeing a difficult patient. Or to give an extra two minutes to a patient that really needs it.
So where should we go from here? We remind ourselves that computers and EMRs are inanimate tools, while patients, doctors, and nurses are people. If the activity isn't dependent on the technology, it shouldn't be subservient to it. That same feeling we have when we're walking behind our dogs, one or more bags of shit in hand? That who's the master here feeling? That needs to be the determining factor of which parts of health care benefit from EMRs, and which ones work just fine with paper. Policymakers, bureaucrats, and administrators need to ask their staff and their clients (yes, the patients) whether this or that service is better with or without the latest toy, and act accordingly and without regret. It's not a baby you're throwing away with the bathwater, it's a machine.